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Letters to the Editor
Optic nerve infiltration in relapse of acute lymphoblastic leukemia Sir, We read with great interest the article by Bandyopadhyay et al.[1] on unilateral optic nerve infiltration as an initial site of relapse in patients with acute lymphoblastic leukemia (ALL), in remission. The authors have indeed reported a rare and important ophthalmic manifestation. Although periodic ophthalmic examinations are to be conducted in patients with acute leukemia,[2,3] we do not agree with the authors’ recommendation that for early diagnosis of ALL relapse, a periodic ophthalmic examination is warranted, as it is extremely rare to develop optic nerve infiltration, as admitted by the authors themselves, and this conclusion would be premature based on a single case report. We also do not agree with the attribution of subnormal vision solely to radiation optic neuropathy. It could be a sequel of the disc edema itself. When commenting on computed tomography (CT) scans in such patients, it is imperative to mention the presence or absence of Central Nervous System (CNS) relapse, radiologically. CT and magnetic resonance imaging (MRI) are more helpful in differentiating optic disc edema due to leukemic infiltrates from true papilledema due to central nervous system involvement.[2,4]
Mohammad Javed Ali, Santosh G. Honavar
Department of Ocular Oncology Services, L. V. Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad – 500 034, India
Correspondence: Dr. Santosh G Honavar, FACS, Ocular Oncology Service, L.V.Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad – 500034, India. E-mail:
[email protected] Access this article online Quick Response Code: Website: www.ojoonline.org DOI: 10.4103/0974-620X.77665
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Bandyopadhyay S, Das D, Das G, Gayen S. Unilateral optic nerve infiltration as an initial site of relapse of acute lymphoblastic leukemia in remission. Oman J Ophthalmol 2010;3:153-4. Shields JA, Shields CL. Intraocular leukemia. Intraocular tumors – A text and Atlas. In: Shields CL, Shields JA, editors. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2007. p. 530-4. Kassam F, Gale JS, Sheidow TG. Intraocular leukemia as a primary
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manifestation of relapsing acute myelogenous leukemia. Can J Ophthalmol 2003;38:613-6. Wallace RT, Shield JA, Shields CL, Ehya H, Ewing M. Leukemic infiltration of the optic nerve. Arch Ophthalmol 1991;109:1027.
Combined posterior flap and anterior suspended flap external dacryocystorhinostomy Sir, We read the article by Deka et al.[1] with keen interest. We wish to express following comments: External dacryocystorhinostomy (DCR) is the gold standard to relieve epiphora due to chronic dacryocystitis or nasolacrimal duct obstruction. The procedure has been modified to improve the surgical outcome. We appreciate the authors for this study. The authors have described the technique of suspending the anterior flaps. However, while describing the operative steps in the article, they have failed to name Baldeschi et al.,[2] who described the technique for the first time. The authors mention that their technique has the advantage of both double flap dacryocystorhinostomy (DCR) and the anterior suspension of anterior flaps. The authors’ conclusion appears to be flawed because of the lack of control group in the study. A high success rate of 98.9% might be attributed to either suturing both the anterior and posterior flaps or to the anterior suspended flap or to both. Ideally there should have been three groups, that is, (1) both anterior and posterior flaps, (2) combined posterior flaps and anterior suspended flap, and (3) Excised posterior flaps and suspended anterior flaps. Despite the controversy regarding the use of a single anterior or posterior flap, or combined anterior or posterior flaps, the success rate of external DCR has been reported to be as high as 93 – 100%.[1-5] Anastomosis by suturing only anterior flaps and excision of the posterior flaps is easier to perform and does not appear to adversely affect the outcome of DCR surgery.[3] A randomized study suggested that DCR with double-flap anastomosis had no advantage over DCR with only anterior flaps, having success rates of 93.75 and 96.67%, respectively.[3] Elwan has also suggested that excision of the posterior sac mucosa may improve the success rate.[4] Baldeschi et al. anastomosed large and mobile anterior flaps of the lacrimal sac and nasal mucosa and passed sutures through the orbicularis oculi to elevate the flaps forward and did not suture the posterior flaps, with a success rate of 100%.[2] Zaman et al. also sutured only the anterior flaps and engaged them in the muscle layer with a success rate of 98.33%.[5] The figure-of-eight vertical mattress suture technique is a recent technique to keep the anterior flap away from the posterior flaps to prevent mucosal adhesion with a success rate of 99.1%.
Oman Journal of Ophthalmology, Vol. 4, No. 1, 2011
